Health and Social Care Committee

In that case, I move to item 2, which is our evidence session this morning. We are continuing our evidence gathering as part of our inquiry into the prevention of ill health and obesity. This morning, we have one witness on this first panel, Dr Jonathan Bone, who's the healthy life mission manager at Nesta Cymru. So, a warm welcome to you, Jonathan, this morning. I should add that we operate in Cymraeg and English, and also we have some Members here on the estate and some Members are virtual this morning.

So, Jonathan, thank you for being with us this morning. We very much appreciate your time. Can you just, perhaps, as an overview, tell us a little bit about the 'Blueprint for halving obesity' across the UK, what approach was taken, and also, perhaps, what engagement you've had with the Welsh Government as well?

Yes, of course. Good morning, everyone. So, just as a bit of background, first of all, the healthy life team at Nesta, we've got the goal of increasing the average number of healthy years lived across the UK. We are primarily aiming to do that through working with other organisations to halve obesity prevalence across the UK, and I'm here, as you say, to talk about our 'Blueprint for halving obesity', which we published back in November. As a quick overview, the blueprint was a two-year collaboration with academics and civil servants, experts across the food, obesity and health system research, and the blueprint really aims to model the impact of 30 different policies that are aiming to tackle obesity, and to allow you to compare the relative impact and cost of these different policies. We think it is the most robust attempt to do this.

As you'll know from the inquiry so far, there isn't any shortage of ideas for how to tackle obesity, but there is a real lack of clarity about which of these policies are likely to be the most impactful, and it can be really difficult to compare two policies together in a consistent way. So, for example, we'll often see evidence for two policies having a directionally positive impact on obesity, but it's really hard to directly compare those two policies, given the way that evidence is often presented. So, the blueprint really aimed to address that gap and help Nesta and policy makers to better understand which of the policies out there should be prioritised.

I can go into some detail about the process for the blueprint itself. So, the first step, really, was identifying which policies to include in the blueprint project. This was done by reviewing reports and national strategies over the last five years, which made recommendations for ways of tackling obesity. From this process, we came up with a list of 150 policies, which was deemed probably too many to be manageable for a project like this, but also wouldn't be very digestible for users as well. So, we went through a process to shortlist this down to 30 policies, based on, firstly, removing duplicates or similar policies. There were lots of policies that were very similar, but maybe had different parameters, different costs around them. We also looked at the availability of evidence and tried to prioritise those policies that were most central to the debate, so, those that are mentioned most often. That left us with a list of 30 policies that cover a wide range of topics, from policies aimed at the retail sector, for example, right through to more treatment-based options as well.

The team then reviewed the evidence around each of these 30 policies. They reviewed the strength of evidence for them and pulled out an estimate for the per-person impact on body mass index for each of these 30 policies, and through this process, the team screened over 3,000 different papers. The conclusions from that literature review of each of these 30 policies was then tested with our expert advisory panel, which included 16 academics, including Professor Susan Jebb, the Food Standards Agency chair, and other prominent academics like Professor Theresa Marteau.

After the literature reviews, the team then used gold-standard modelling methodologies to transform that per-person impact on BMI into national impact on obesity prevalence. Alongside that modelling work, the team also commissioned a consultancy called HealthLumen to estimate the costs to both Government and to industry of each of the policies, and the benefits that would be attributed to Government if they were able to achieve those decreases in obesity.

Thank you, Jonathan. Before I ask Members to come in on, perhaps, some specific areas, you'll be aware of our work. We want to make recommendations to Government to deal with and tackle the obesity crisis. Have we got an obesity crisis?

Yes.

Yes. So, we want to make recommendations in that regard. So, when it comes to your blueprint, perhaps in bullet-point form, what would be your key priority areas that you think that we should be recommending to Government that they need to tackle? But also considering cost elements as well, because it's very easy for us as politicians to make recommendations to Government that cost a lot of money. What are the low-hanging fruit, the areas that might not cost much money as well, that you think we could be recommending that the Government in Wales addresses?

Sure. So, I think the first thing to say on that, the size of the crisis, is that there was a piece of work that Nesta did last year that analysed the number of people living with obesity in Wales and found that around one third of adults in Wales were living with obesity. So, that's more than any other part of the UK, so we think there is a real need and opportunity for Wales to lead the way in effective interventions. As you say, we need effective interventions that are also low cost, ideally, and I think the blueprint did show several things that Wales could do that meet this criteria.

Tell us your top three, if you like.

Yes, sure. So, I think, generally, the most cost-effective policies tend to be those that make eating healthy simpler, particularly in large grocery retailers where we do get most of our calories. So, I think, if I was going to pick three, as you say, the first one I'd stick with was banning all price promotions on less healthy products in medium and large retailers. So, just to give you a little bit of detail on this, this would be proposing going further than the legislation that's currently being drafted by Welsh Government, which is really focused on volume price promotions, so buy one get one free, that type of thing, and extending this to temporary price offers and introductory price offers, so more, 'It was this price, now it's this price.' The modelling suggested that this would lead to a 29 per cent relative reduction in obesity rates, which is 40 times more impactful than the volume price promotions policy currently being drafted.

So, you said that you would go further than what the Welsh Government has drafted at the moment. So, just help me to understand how can the Welsh Government go further.

The current legislation that's being drafted is looking at the volume price promotions, so this would extend that to a wider range of price promotions by retailers.

Right, okay. And would there be, in your view, any unintended consequences of that, or do you think that would be a quick win for Government, with no unintended consequences?

One argument that's often raised against the price promotions is the impact it might have on people's shopping prices, particularly those in low-income groups, but there has been evidence to show that, actually, when a shop is done without price promotions, you don’t spend more money. I think it's important to remember that retailers aren't trying to give away freebies, they are trying to influence us to buy more things.

I interrupted, sorry. That was No. 1, and I did say three, didn't I? You can have others as well, because others may ask questions afterwards that can prompt into other areas, but, as a starter, I was just looking to your three, perhaps, top priorities.

Three. I think the second area I'd suggest prioritising is a policy that might be less familiar to those in the committee, which is a Nesta-proposed policy, one that we've developed, and it's around setting mandatory health targets for large retailers. That simply involves setting targets for these retailers to increase the average healthiness of the food they sell.

I think what's really interesting about this policy is that it does give the retailers flexibility on how they achieve that goal. So, it's very based on the outcomes, which means that we can draw on retailers' knowledge of their customer base and what they can do without harming their profits. The modelling that Nesta did around this estimates that setting health targets for the 11 largest retailers at similar levels to today's best players would lead to an approximate 25 per cent relative reduction in obesity rates. Although, just to flag, I think this is one of those policies that could make most sense to do across the UK, particularly, in collaboration.

Sure. And I said a third as well, didn't I?

So, I think I'm going to go outside of those that are already in the legislation, and I think not all responsibility should be with retailers. I think that the out-of-home sector also has a role to play in this. So, that's restaurants, pubs, cafes. I think we've all found it hard to find healthy options when we've been short on time, or at work, or travelling. There's been some recent evidence that suggested, from Nesta, that two thirds of out-of-home meals are more than the 600-calorie guidelines for a single meal, which I don't think would be a problem if it was a rare treat, but we've also found that eating out of the home is no longer that rare treat. Around 60 per cent of people eat from the out-of-home sector at least once a week, and 11 per cent at least once a day. So, one particular policy focused on the out-of-home sector would be a ban on price promotions on high fat, salt and sugar products in out-of-home businesses, which we've estimated would lead to a relative reduction in obesity rates of 2 per cent. Although that's quite a bit smaller than those in the retail sector, it's still a really meaningful difference.

Sure. I'm going to look to bring John Griffiths or Mike Hedges in now, but I'm very happy to keep this a free-flowing discussion. John, I think you indicated. I'll bring you in first, John, then Mike. John.

Bore da, Jonathan. I wonder if, first of all, Jonathan, you could tell us a little bit about what you mean by health targets, that there might be mandatory health targets for larger retailers. What would those health targets consist of?

That is a policy that has been developed by Nesta, so it is one that you'll be less familiar with. The targets would be based around setting sales-based nutrient-profile-model targets [Correction: 'sales-weighted average nutrient-profile-model score targets']. So, you'd be looking for an average nutrient profile score for the products they sell. There are different ways that they could achieve that, through things like positioning, price promotions.

Okay. Jonathan, I take it from your top three, as it were, in terms of effective interventions, and I can readily see the sense of this, it's easier to get the food, the retail sector, perhaps manufacturers—. If we could get them to change to healthier products and healthier operation, then that's a lot easier than trying to change people’s behaviour, really, isn’t it? It’s a much more direct and effective way of dealing with these issues. Would you say that that’s at the heart of your top three, as it were?

Yes, definitely. We definitely think that approaches that change the food environment and make it easier for people to make healthy choices are going to be more effective than those that rely on people, individuals, taking actions—intentional actions—themselves. And I can say a bit more about why that is.

I think the first point is that, over the last 30 years, the majority of Government strategies have focused on policies that do require individual action, and, over this time, obesity rates have doubled. So, these kinds of approaches clearly aren’t working.

I think another reflection on that doubling of obesity rates over the last 30 years is that it’s not really realistic to think that the reason for that is that people have somehow decreased in the amount of willpower they’ve got, or ability to make these choices. I think what’s much more likely is what we already know about the food environment, that it has made it more difficult to eat healthily. So, we’ve seen portion sizes increase. We’ve seen fast-food outlets become more abundant as well. So, that really is the focus there; we think that those kinds of improvements will be more beneficial.

Okay. Chair, perhaps I could ask, if we have time, a few questions on children and young people, and some of Nesta’s work around the blueprint. Jonathan, it’s perhaps a little bit counterintuitive to look at some of your findings, for example, in terms of school-based physical activity, nutritional education in schools, and reducing the number of takeaways around schools, in that those interventions are viewed as having very low impact on obesity.

So, could you just say a little bit more about that? With physical activity, for example, you would hope that if children became more physically active in schools that it would have an impact on obesity rates. Is it something to do with how well those physical activity initiatives and nutritional education initiatives are done, or is it the case that, no matter how well they’re done, they’re not going to have a huge impact?

Yes, of course, I can say a few things on that. I think the most important point here on the physical activity is that physical activity has lots of health benefits that go outside of obesity, and this blueprint was very much focused on obesity reduction. So, although you’ll see a 0 per cent reduction [Correction: 'you'll see the blueprint predicts a 0 per cent reduction in obesity rates'] for the increase in school-based physical activity, it would likely have broader health benefits, and I think that’s a really important point to make.

But why it has a smaller, perhaps, than you expected impact is that you really do have to exercise quite a lot to burn significant calories to make a difference to obesity rates, which means that policies that are focused on stopping excess calories being consumed in the first place are likely to be much more effective than physical activity. It’s also around the fact that, although these types of school-based physical activity are likely to have a small impact on BMI, the £100 million of spending [Correction: 'spending across the UK'] that this policy was modelled around, we estimated, would only be able to reach around 25 per cent of children with excess weight. So, it’s a bit about the reach, as well, of that programme.

I can talk a bit about the nutrition education, as well, if that’s useful. So, the impact of that policy was based on a systematic review—so, on a good evidence base—that found no significant impact on children’s BMI. There is potential that these types of interventions could have longer term impacts that weren’t measured by the studies, into adulthood, but there wasn’t any evidence on this. And I think this really reflects some of the challenges with more educational interventions more generally, that they don’t really help address that gap between knowledge and action. So, it can be really hard to enact the knowledge we have about nutrition in the current food environment, which makes it very hard for us to make healthy choices. And I think that’s probably something that we can all relate to. I think we’ve all got a decent understanding of nutrition now, but that doesn’t mean we always make healthy choices. I certainly don’t.

No. I guess as well, Jonathan, that a number of initiatives might have a relatively small impact on their own but, taken together, they could be significant, and no doubt that's factored in to your work as well.

So, I think that that was one of the challenges with this blueprint, that we weren't able to model how different interventions interact with one another, and that's because the evidence just isn't really out there to do that. So, it's of course possible that some policies positively interact with others, but also possible that there could be negative interactions as well.

I see. Okay.

Mike. Did you want to come in at all, Mike?

Diolch, Cadeirydd. The Welsh Government intends to make regulations to restrict the promotion and placement of high fat, salt and sugar foods within the retail sector. There are other things that they could do, like putting a limit on or control over the number of calories in a meal. I was brought up in a generation where, 'Eat it all up' was what you were being told, and as they make meals that are bigger and bigger, with 2,000 calories not being unusual in some of these meals, is there a case for actually doing something about very high calorie meals?

So, the majority of these interventions are focused on those that are HFSS, which are generally high in calories and that's why they were chosen as the focus of this. I'm not sure—. Are you talking about a cap to calories, or something like that?

What I'm talking about is what I always talk about, it's actually having a red sticker on something that is above 1,500 calories.

Okay, so more about labelling.

Yes.

So, yes, there are approaches to labelling, such as the Nutri-Score system and front-of-pack labelling, which could have a moderate impact, at least, on choices. I think compared to those policies that actually focus on changing the food environment itself rather than relying on people to look at the label and make a decision, it's probably less impactful, but still could be an important measure to take.

Okay. Diolch.

I suppose another question I'd have, Dr Bone, as well, is: in the blueprint, it talks about increasing the number of people who have access to medications. I wonder if you could talk to that point.

Yes, of course. Yes, these GLP-1 agonists are obviously—there's a lot of progress in this area and a lot of interest from the media and policy makers. I can talk a bit about those. I think it's uncontroversial to say that these types of drugs are highly effective at supporting weight loss. There's been evidence to suggest that, on average, they lead to a 15 per cent to 20 per cent reduction in weight over just a few months, and they've been deemed to be cost effective by the National Institute for Health and Care Excellence. I think that the main point here is that rolling out these drugs to all people with obesity would be extremely expensive. We've done some rough—very rough—calculations that suggest that it would cost about £2 billion to roll this out to all people in Wales.

How much?

Two billion pounds. To all with obesity in Wales. That is a very rough calculation. But it [Correction: 'we estimate this'] would lead to a 41 per cent relative reduction in obesity rates. A more moderate approach that we also modelled around would be to ring-fence around £25 million in Wales for these types of treatments, which we estimated would lead to around a 2 per cent relative reduction in obesity rates. It's probably important here to flag that there are challenges to this type of drug. Most of the weight is put back on after people stop taking it. So, they would have to be funded in the long term. There are also issues around the side effects and the long-term safety is under consideration. But increasing funding to these drugs, I think, could be a way to have an impact on obesity rates fast, which could, of course, be life saving for those, especially, with severe obesity.

Can I just ask about that, though? There's a huge cost attached to these medicines, but the concerns that we've had put to us is that, once you've finished taking the medications, then you regain weight, so, that tells me that it's not money well spent, that it's not an effective long-term medication.

Yes, I agree. I think it's definitely not the solution on its own. I think it should be taken alongside a wider, longer term strategy to improve the food environment. But, as I say, I think it's also worth reflecting that it is the opportunity to have some quick benefits that could save lives now as well as thinking, in the long term, about how we improve the food environment at the same time.

Okay, thank you. And John or Mike, do you have any questions on this area around medication at all?

Not on medication, Chair, but I would like to ask again on children and young people, if that's okay.

Yes, sure.

Yes. The blueprint, Jonathan, included an intervention on the UK Government's universal BMI monitoring for children in reception and year 6, which was rated as having a very low impact on obesity. I just wonder if you could say a little bit, perhaps, about why you think that may be the case. And here in Wales, the height and weight of children is only measured at age 4 to 5 in reception class, so, I wonder if you could say anything about that situation in Wales and how that relates to, perhaps, obesity levels.

Yes, sure. So, the first thing I'd say on that is that we would recommend that Wales extends their programme to measure weight and height at year 6 as well, because it's very important for us to understand how obesity rates are progressing, both in order for us to target interventions more effectively, but also to understand the impact of interventions currently in place.

I think the reason, really, that this has a 0 per cent impact is because it's really how you use the data that's important, not just having the data itself. Although there's a potential route to impact through letters home to parents, informing them of their child's BMI, there was a 2014 evaluation of the National Child Measurement Programme in England, which looked at this and found that these letters led to no impact on dietary behaviours at home. So, yes, we think that data and the insights from that data could be really important, but just having the data on its own isn't going to be the thing, obviously, that leads to impact.

And just as well, if I may, Chair, on intergenerational interventions, does the blueprint include any intergenerational interventions that have been shown to help break that cycle of obesity within generations?

Yes, so, the blueprint includes a policy around increasing referrals to family-based obesity prevention programmes, and these are normally commissioned by local authorities and help parents and families change eating and physical activity habits. It predicted a 0.04 per cent relative reduction in obesity if funding for these types of programmes were extended by £85 million per year—across the UK that is. I think the key thing that's limiting the benefits of this is that they're quite expensive to run, so, without a lot of funding, you're only reaching a relatively small section of the population. But also, to the point that I was talking to you about earlier, actually, just providing education without changing the environment itself doesn't overcome the biggest challenges here.

So, I think one thing to flag on this as well is that the effect sizes we use to model the impact were based on some really good evidence—so, meta-analysis from 2013—but that also showed that there was a lot of variation in the impact of the obesity prevention programmes that were included in the meta-analysis, which suggests that it probably does make a lot of difference how these programmes are actually delivered, and there's quite a lot of variety in that.

Okay. Diolch yn fawr.

Thank you. Thank you, John. In your opening summary, Dr Bone, you focused quite a lot on retail, but what about manufacturing as well? Because it seems to me that retail and manufacturing, they're the key areas to intervene on in terms of tackling obesity. But tell us about the manufacturing process—any recommendations that you could make in that regard, or how the blueprint addressed those areas?

Yes, of course. So, in the area of manufacturing, the most impactful policy that was modelled by the blueprint was around a tax on sugar, salt, and salt in processed foods and those used in restaurants, and that would be very similar to the existing soft drinks industry levy, except it would be extended to a wider range of products through a £3 per kilogram tax on sugar and a £6 per kilogram tax on salt. That's very similar to the tax that was recommended in the 2021 national food strategy. We estimated that would lead to a relative reduction in obesity rates of 12 per cent.

Right, okay. And any other areas in terms of retail? I mean, you focus heavily on your top three on retail, but, because that is such a significant area, any other areas that you'd want to highlight beyond the areas you mentioned at the beginning of the session?

Yes. I think a couple more on manufacturing and retail, which kind of, obviously, cross over. I mentioned the soft drinks industry levy. We also modelled the impact of extending that tax to also cover milk-based drinks, which we found would result in a 0.6 per cent reduction in obesity, and also investigated the potential impact of incentivising reformulation of HFSS products through grants to manufacturers. That policy was based on £500 million of grants being given out across the UK, so that could, for example, be through expansion of the food industry Wales programme that already exists. We estimated that that would lead to a 1 per cent relative reduction in obesity. So, out of those three, as I said, the first one, which would be a wider tax, would likely be the most impactful.

Sure. I've got a couple of other questions as well. But, just looking to Members, any Members want to jump in at all on any point? No.

So, the other issue, Dr Bone: we talked a lot about the blueprint as well, but, outside of that work, and in your wider work, are there any other recommendations, do you think, that you could make to us that you think we should be addressing with the Government?

I think the blueprint covers a very wide range of policies, so I don't think there's anything that comes to mind other than the fact that we think that obesity should really be prioritised by Welsh Government as something to tackle, given its huge impacts on health and on health inequalities as well.

And I suppose finally from me, we've asked lots of questions this morning to prompt you, but is there anything else that you think is important beyond what we've asked that you think we need to be aware of, or we should incorporate in our work when we're considering making recommendations to the Government?

I think just to highlight the real importance of improving the food environment primarily, and that policy should be focused on that, rather than on, necessarily, education or campaigns, things like that. We really do think that those types of policies are likely to be the most impactful.

Okay. I'll just bring Mabon ap Gwynfor in as well. Mabon.

Thank you very much, and apologies that I was late joining you. Thank you for joining this meeting. I hope that this question hasn't been asked already. One thing that struck me: we've seen in the last few days discussion of stopping the selling of fast food in shops, meal deals of crisps and sandwiches and a drink, those sorts of deals. Don't you think, rather than stopping that, it would be better to encourage other types of foods to be eaten instead? So, rather than that chocolate and crisps are the snack, that they provide fruit as a snack. Would more positive encouragement like that have a better influence on people?

Thank you. So, the question was around more positive types of interventions. I think, generally, the thought is that, through a lot of these restrictions, they would result in—[Correction: 'healthier products taking their place']. So, through things like the banning of the positioning of HFSS food, which is obviously something that Welsh Government's already introducing, the hope is that more positive, healthier products would replace them in those areas. So, we think that these policies won't just be negative; they will also encourage healthier products to be eaten. Some of the other more grant-based programmes, so I mentioned the incentives for HFSS reformulation as well, which would be providing grants to improve the food itself on offer.

I don't know if Mabon wants to come back or not, but if not, on the back of Mabon's question, I suppose we put a lot of emphasis on retail being responsible, but what about individual responsibility and parental responsibility, especially, I'm thinking, in terms of the context of Mabon's question about snacks, for example? That requires a culture change, so what are some of the steps to make that culture change do you think could be supported by Government?

I think on that point around personal responsibility, I really want to go back to that point that I raised earlier that, really, this has been the focus of the last 30 years of strategy, educational campaigns and the like, which have tried to rely on people's personal responsibility, and they just haven't really worked. Obesity rates have doubled over the last 30 years, and that's really why we're focusing more on retailers and manufacturers than on the individual here.

Yes, I accept it. For me, I think all committee members have a dilemma; it's how much Government needs to intervene and how much we take account of people's personal responsibilities as well, and the parents' responsibility in terms of how they persuade their children to eat in the correct way.

I think maybe if—

If I could come back in—

You go ahead.

One of the lines I've been looking at in the consideration of this subject over recent months is poverty—the link between poverty and people's food choices and health circumstances. We know that there's a clear link there, and that if somebody is living in even comparative poverty, their ability to choose healthy food is more difficult. It's easier to eat food that has high sugar, salt and fat levels because its availability is so much greater and it's cheaper. So, what are the steps, do you think, to go back to that positive point, that should be taken to ensure that vegetables are cheaper, that it's easier for people to prepare food with vegetables rather than buying a Big Mac or a pasty, or whatever, from Greggs? How can we do that using the Government's power to nudge or legislate?

Thank you. I think a really important point to raise on this is that the range of policies that I've just discussed today, the majority of them from a health perspective, especially those focused on HFSS foods, will likely benefit those on low incomes more so than others, given that, in general, obesity rates are higher in lower income groups, but also that HFSS foods are typically consumed more often. A really important point to make here around the difference between those policies that require personal action and those that are focused on improving the food environment in relation to health inequalities is that, generally, those policies that require more personal resources, more time, more mental attention, more money—so, we're talking about things like education, or campaigns on nutritional education—they tend to work less well for those without those resources, which tend to be lower income groups. So, actually, those food environment-based interventions tend to be better at addressing health inequalities.

I think the question of how you bring down the prices, for example, of fruit and veg and healthier products is a really good question, and one I don't have a good answer to today. It's something that Nesta are currently exploring in more detail. I think there are some interesting avenues of work around the potential for subsidies. We've got things like the Healthy Start vouchers, and it would be interesting to explore how they could be made more effective for obesity itself and cater to a wider range of people.

Thank you. Dr Bone, thank you ever so much for your time this morning; we do really appreciate it. Is there anything else you think you want to add? Do you think you've covered everything—

No, that's great. Thank you very much for your time today.

Thank you so much, and we really appreciate your time and your advance paper as well, so thank you very much. Diolch yn fawr iawn.

Great, thank you.

We'll take a five-minute break and be back just a little bit after 11 o'clock.

Welcome back to the Health and Social Care Committee this morning. We do want to just jump to item 5.

So, under Standing Order 17.42, I ask Members to resolve to exclude the public from item 6 of today's meeting and the meeting on 19 February, when the committee will be considering our report on the legislative consent memoranda for the Tobacco and Vapes Bill. Are Members content with that? Yes, they are. That's great.

In that case, I move back to item 3. We are currently continuing to take evidence as part of our inquiry into the prevention of ill health, obesity, and we have a panel in front of us this morning to focus on a particular area. So, I'm grateful to our witnesses for being here today. I wonder if you could introduce yourselves just for the public record, if I start on my left.

Bore da. I'm Rocio Cifuentes, Children's Commissioner for Wales.

Bore da. My name is Dana Beasley. I'm a general paediatrician here in Wales, but I'm here representing the Royal College of Paediatrics and Child Health.

Julie Richards, director for the Royal College of Midwives Wales.

Lovely. Thank you all for being with us. Members have different questions. I'll kick off with the first question. What advice and support is available to expectant mothers in relation to having a healthy weight during pregnancy? Perhaps I'll come to you on that one, Julie.

I'm happy to pick that up from the Royal College of Midwives. Obviously, as midwives, we are the first point of information when women and their families book with us for a maternity care episode. But what we would advocate is that, actually, with the women's health plan, we really want to focus on the pre-conception period of time. So, there is great opportunity to improve the health and well-being of all of our nation in Wales here. So, if we could encourage people, prior to their pregnancy, to have the optimum weight position, that obviously goes on to improve both their well-being during pregnancy, but also the future well-being for infants as well.

To draw the committee's attention to the 'State of Maternity Services' report that the Royal College of Midwives produced back in June 2023, that did show that we've got a continued increase in women who are booking a pregnancy with an increasing BMI. So, by the time people join the maternity services, at that point in time, obviously there's work that can be done for weight management, but we are certainly noticing an increase in BMI. And while services will continue to offer good services during that time, if we could have done more pre conception, that could have really helped and improved.

Okay. That's a fair point. Perhaps we'll come back to that point as well later. But in terms of supporting expectant mothers, are there equitable services in that regard, in terms of what you've talked about, across Wales?

We would continue to advocate that we need to have good investment into maternity services, so that we have midwives who are well equipped and well able to support during the antenatal period. The benefits, as well, of having specialist midwives and consultant midwives is really important—

I'm asking about the services now, though. Are the services—? What are the services, in your view—? Are they good services at the moment, and are there gaps across Wales where there are some areas that are not performing as well as others?

There is opportunity to improve and the fact that we've got the published quality statement for maternity and neonatal services, which has been published this week, gives us an opportunity to really set out what the good standards look like. Compared to many parts of the UK, we do have a reasonably good service in Wales, but we certainly could see improvement. When I approached health boards, knowing that we were coming today, they also certainly reported that they are needing to strengthen, maybe, some of their work with some of the bariatric services as well. Obviously, women with an increased BMI would have an increased level of complexity, so it's really important that we have a linkage up with the multidisciplinary team and the specialist services to support women.

So, just to talk to the point about, perhaps, expectant mothers who are living with obesity, tell us about how they are supported.

So, they would be supported with—. Obviously, all women have a midwife. But then, women who go into a more complex pregnancy will need to be supported by the obstetrics service. Then, there may be some need of—. If there are some comorbidities, such as diabetes, they would need to then be supported by specialist diabetic services. And then, if you are also at the threshold of bariatric services, you would be accessing the specialist services. So, it is about cross-cutting across a range of services, depending on the position of women's health.

And you are talking about specialist services there. So, is there equity of service across Wales, or are there gaps there as well, in terms of some parts of Wales having better support or a lack of particular services?

So, the Royal College of Midwives has seen growth and improvement, particularly around the care of women with diabetes. It has seen an increase in some of our specialist midwives. It has seen an improvement, a commitment to consultant midwives, when you compare us to other parts of the UK. But with the increase in BMIs, the more that we can do to support and the more that we can do, as well, to support people to have more optimum health, either post pregnancy, or preconceptually as well—.

Okay. Thank you. I will bring in Mike Hedges at this point, if that's all right. And please, if you think that you want to come in, just indicate as well, if you want to come in on a particular point. Mike Hedges.

Diolch, Cadeirydd. What are the current breastfeeding rates in Wales, and what can be done to encourage breastfeeding and provide support to mothers to breastfeed?

So, we are very fortunate that we have a good initiation rate for Wales. What we do find is that those rates often drop off into 10 days and then further into six weeks. I know that my fellow colleagues here will also want to talk about the fact that, actually, what we can strive to do much more is that optimum, where we can have exclusive breastfeeding up until six months. When you look at the rates for Wales, they are considerably lower when you compare us to other parts of Europe. If I draw on the Public Health Wales figures, they show that, in Norway, 71 per cent of women would continue breastfeeding up to six months, whereas I know that my colleagues have got data that will show that, in Wales, that is considerably less.

In preparation for this, I looked the data up and the initiation rates rise, and they are currently at 63 per cent, which is wonderful to see. But then, when you look further after six weeks, it's only 41 per cent. So, less than half have sustained for six weeks, and then it drops to something like 29 per cent at six months, which is a very small number.

Now, breastfeeding is something natural, but it does need support, is what I'm trying to say. As a general paediatrician, we often see little babies being admitted to hospital with some weight loss because there have been difficulties. What I would like to see is, probably, better support in the communities, closer to home for mothers because, by the time they come to see me in hospital, the horse has bolted.

Could I just add that I agree with what both Julie and Dana have said, but, just in terms of the importance of that community support, to highlight the important role of health visitors? We do see disparities in health visitor contacts across different health board areas. So, I would really like to see that particular aspect being a focus of the review of the Healthy Child Wales programme, which has been announced, because I think that that is a really important factor in supporting and sustaining breastfeeding.

Thank you. Mike, did you want to come back? Sorry, Mike, are you happy for Mabon to jump in, and I will come back to you?

Please.

Yes. Mabon.

Thank you very much. I know that Mike is going to follow up on this point, but in terms of the context of this, very briefly, could you explain, when we look at obesity in children and adults, why it's important for babies to be breastfed? What's the connection between breastfeeding or breast milk with the health of children as they grow up?

I’ll start with this, shall I? So, breast is best. As simple as that. Breast milk is natural, it’s free, it contains everything the child needs. It gives you immunity against certain diseases. It just lays the best foundation. It is very difficult to overfeed a breastfed child. Most women will be able to breastfeed with the right support. It is important that women have choices, but it is important that they’ve also got the knowledge that breast milk is just the best and will set the best foundation for a healthy child.

Thank you.

I'm happy to add as well, from a research point of view, exclusive breastfeeding has clearly—. There’s a number of research and evidence bases of how it does clearly make a huge difference to the longer term health benefits of the baby and particularly reducing obesity. So, it is the thing that we could invest the most in to really make a difference to our future population. It can also have a huge impact on reducing future gestational diabetes, as well as there being lots of health benefits to mum: again, further reducing obesity, further reducing diabetes, and further reducing breast cancer. So, there are clear huge benefits.

Okay. I didn't realise that aspect. There is a health benefit to the mother in terms of supporting having a healthy lifestyle.

Yes. Those are the physical benefits, as well as the emotional benefits. So, if you’ve got good attachment, good feeding, right from the outset, you’re also less likely to have an emotional impact as well. So, it’s the physical and the emotional impact. But the evidence base around the physical benefits to both mother and baby are profound.

Okay. Thank you.

And well supported by very strong research.

Back to you, Mike.

How successful has the Welsh Government’s five-year breastfeeding action plan been? As the current plan is coming to an end, what needs to be added to the plan for the next five-year plan?

Okay, I’m happy to be part of that. I’ve been a strong member of the steering group around the breastfeeding action plan, and I was in fact talking to the chief nursing officer and the chief midwifery officer about it this morning. The benefits of that plan and what it can influence from a multilayered perspective, again, we were talking about this; yes, there are responsibilities and things we’d like to see from a health point of view, particularly that strategic lead for infant feeding across all health boards in Wales, but also it’s about influencing society, it’s about influencing social norms, it’s about providing good information so that we are all informed about the physical, the emotional, the impacts. But these are things that we ought to be doing society wise.

We did notice in COVID that the numbers for the continuation of breastfeeding significantly increased because people were able to stay at home, have time with their babies, sit and feed their babies, not necessarily have the challenges of going back to work. One of the things that the Royal College of Midwives is going to be campaigning for is support for people to be well supported when they go back to work, as well, with the continuation of breastfeeding. So, there are a number of recommendations that we would love to see continue through the infant feeding action plan and the continuation of that work, because I think it has such a huge benefit for so many reasons.

Sure. I'll just ask, do you want to come in on another question, Mike, and then I'll bring in Dr Beasley?

Yes. How effective are the Healthy Child Wales programme and the making-every-contact-count approach to improving dietary and physical activity?

That's probably a good question for you, if you want to comment on the other question and that one as well.

That is probably a question for me. So, the healthy child programme has really good intentions, but the difficulty that I see is that it’s drawing on an overstretched workforce. So, again, we’re coming back to workforce. We’ve got a programme that’s designed to help and support, but really we can see that there is not enough support in the communities. The number of health visitors hasn’t really increased. We know there are not enough contacts, and that could be improved. I think Healthcare Inspectorate Wales are doing a whole workforce review at the moment because that is so, so important. We need that support in the community.

The other point was that we need to lay the foundations there. We can educate our workforce to a really high degree—and lots of programmes do, and that's all wonderful—but it will only work if our families have got the opportunities, and we do know that not all families do have those opportunities. So, we're here to talk about obesity, and obesity is strongly linked to poverty, and that makes things very tricky.

Sure. Thank you. Mike.

Finally, on the breastfeeding and healthy child question, what are the witnesses' views on the uptake of the Healthy Start scheme and on any issues in it that need to be addressed? And, can I go back to the first answer you gave about the reduction in breastfeeding? How much of that is lifestyle and decision choice, and how much of that is caused by parents reaching a stage where they're no longer able to effectively breastfeed?

Do you want to come in about the breastfeeding, and sustaining breastfeeding?

So, the sustainability of breastfeeding, as you say, could be influenced by a whole range of things. It can be influenced by different generations. I can just draw on my own personal example of trying to influence my dear late mother, who was part of the 1970s, who had a very strong view of bottle feeding. So, it's about how you influence generations and how you also influence families. So, it is that we all see that commitment to support a breastfeeding mum, but also how we are very equipped in society to support people to be coming out and about and to feel comfortable and well supported to be breastfeeding is important. And then, as I've also alluded to in my previous conversations, it's about how we support our working practices when people are planning to come back to work or do things, and how we can support them with flexible working and good support for breastfeeding. So, there are a number of things that can make a difference, just to create those expectations, isn't it, of our families.

Yes, normalising breastfeeding at home and in public is really important. There is a little bit of data there. Usually, we don't have enough data, but I think I've seen a little bit of data that we know that, generally, older mums tend to breastfeed more compared to younger mums. We know, looking at ethnicity, that women from a black background often feed longer, more successfully. And we also know that, again, women who live in deprived areas are far less likely to breastfeed. So, that's where we then have to put our resources, because we know that these women, young women in the deprived areas, will be unlikely to breastfeed. So, we need to find out what the barriers are and put the extra support in those areas. That's the question on breastfeeding.

You mentioned Healthy Start. Healthy Start is a lovely initiative, but there have been issues with uptake. I know this is not devolved, but, from my point of view, there is strong evidence there that it helps to support families and children thinking about a healthy start in life. But, if you look at who's eligible and what, actually, the provision is—£8.50 a week—if you happen to not be able to breastfeed, that barely buys a tin of milk. So, those values have not really been updated since, I think, 2021. And the other thing is the uptake. The uptake has been very low. There has been some e-learning programme introduced to increase the uptake, but the uptake is still only in the 70s, and there is some regional variability. So, what we would actually like to see is an expansion of the Healthy Start scheme. It needs to be brought in line with inflation. It should be expanded to all families receiving universal credit. And, in my view, it should also be an opt-out system, an auto-enrolment, because then we have everybody involved right from the start. That would be what 'good' looks like at the beginning.

Okay. That's great, helpful evidence. Mike.

Moving on to health and nutrition knowledge—and this question's in two parts—are parents aware of what a balanced diet ought to be for their children, and then, are they able to afford it? There is a cost-of-living crisis, but I've lived most of my life when there has been a form of cost-of-living crisis most of the time. So, people, a lot of the time, can't afford the good, healthy option; they can afford the cheap, filling option. So, do parents know what they should be doing, and then are they financially able to do it?

Rocio.

Thank you. Yes, poverty is the biggest factor impacting on discrepancies and inequalities in relation to obesity and breastfeeding and awareness of good nutrition. The Food Foundation published a report this year showing that 1,000 calories of healthy food costs £8.80 compared to 1,000 calories of unhealthy food costing £4.30. So, healthy food currently is more expensive, and that is a reality that parents who are struggling will have to grapple with, and will have to make unhealthier choices. They will be forced to; their financial circumstances will dictate that.

I think much more could still be done to increase awareness, nevertheless, and in schools; I'll talk mainly about what's happening with children to do this. I think there are some promising initiatives. I've heard some really good local examples of young people being effectively engaged in their food environments. I know Castell Howell are aiming to work with six schools in five local authorities in south Wales. They're looking at visiting farms, tasting fresh food produce.

So, I think there is reason to be hopeful in relation to children being more connected and increasing awareness about food and being more connected to where food comes from, which will increase their appetite for healthy food, but I'm not sure whether that's being effectively extended to parents and the whole school community. I think more could be done there. The community-focused schools programme could be effectively targeted and could be asked to look at food more specifically. That would be an opportunity to explore. And I think that whole-community approach to better understanding and connection to food is really, really essential if we're really going to shift the dial on this. We've had decades and decades of obesity figures going in the wrong direction, and the evidence that Public Health Wales submitted to this inquiry tells us that nowhere in the world has actually successfully managed to shift things in the right direction. So, it shows that we can't just keep doing the same thing in the same way and expect different results. That's the definition of madness.

We have to have, I would say, a paradigm shift in how we actually think about obesity. And for me, the shift that's needed is that we're looking at the wrong end of the problem. We're looking specifically at the outcome of the problem. Obesity is the outcome of poor nutrition and lack of exercise and activity. And that, to me, is where the fundamental issues and inequalities are. It's about access to good food, nutrition and activity, and, if those two things aren't there, the outcome will be obesity. But I think we need to look at things very differently.

Thank you. Mike.

Right, back to me. Sorry, I was wondering if anybody else was coming in. Well, the final question from me is that there's not equity in communities. This is going back to what Rocio said earlier. Thank you very much to the German retailers who have allowed cheaper food into some of our poorer urban communities, as opposed to the more expensive food that was available previously. But how do we make sure there are equitable opportunities to make healthier choices? It's okay for those with a car, able to drive to the out-of-town supermarket and able to make decisions around that and, in many cases, not worrying about how much it costs. How can we ensure that communities that have financial problems have equitable opportunities to make healthier choices?

Do you want to take that, Rocio?

Yes, this is a big challenge. I think there have been local examples of good practice that we could learn from, and I would really like to see those good practice examples scaled up and made into a national programme, particularly focusing on developing children's understanding of food in schools.

Tell us about those local examples then.

Those examples: Carmarthenshire County Council did a school menu redesign; they called it a 'future generations' school menu redesign and they looked at their local and their regional assets, and looked at what assets they could draw on in their local communities. Cardiff Council ran a food hour where every child had to spend at least an hour a day in school working with food, and learning about nutritious food. And there's another example called the Cookalong Clwb where children learnt how to make a healthy chickpea korma. This one worked with over 800 children. So, there are good examples, but it's not joined up, and I know that the future generations commissioner has called for a national food strategy to make sure that we are connecting up these good initiatives and connecting food suppliers to food consumers and doing that in a sustainable way. So, I would very much support that call and hope that children and communities could be the connections between that strategy.

I would wholeheartedly and 100 per cent agree with what Rocio has said. A national food strategy and a vision for food in Wales is definitely needed, joining up lots of good evidence. You've heard evidence before from Food Sense Wales from Simon Wright. But I think the communities and schools are key because they provide the perfect opportunity. Children want to learn. Children are so easily engaged if you engage with them positively. There are so many good examples of community farms as well where children are taken to a community farm, they plant seeds, they harvest potatoes, they eat them. There are some charities who work with schools. They grow kale, they eat the kale, and those children ask for kale. I mean, that's unheard of, but it does work, and there are plenty of those examples that have worked because you can enthuse children and you can educate parents along the way and get them involved.

So, if you grow food locally, that would be so much better, because the big supermarkets, again, where is their food coming from? We're looking at fruit, we're looking at things like that, they're travelling halfway around the world. So, we need to also focus on local food that's in season because that, again, nutrition is going to be so much better.

Sure. I can see examples in my own constituency where those programmes happen, but children actually then go home and teach their parents these different good practices. So, absolutely. Yes, sure. Thank you. Mabon ap Gwynfor.

Thank you very much. I want to expand on that point, if I may, on schools and using local produce. I'm fortunate to live in a rural area, so I see agriculture around me every day. But, of course, if we want to see fruit and veg developed and grown locally, we need to do that at scale. We don't necessarily have that scale. That is, the fruit that we get—. I have a company in my constituency that imports fruit to make jams and so on. They have to import it all from Poland because they can grow all of it at scale in Poland; we can't do that here.

This is going beyond your expertise a bit, but, as you've already mentioned it and we're discussing the principle of growing food locally, how is it possible to do that if it's not possible to do it at scale, because it's not affordable then? And I go back to this point of ensuring that food is affordable for people. If we can't grow and produce food at scale affordably, then we can talk about the idea to the nth degree, but if it's not deliverable it's not going to happen. So, do you have any ideas about that? Has it occurred to you how we would achieve that aim?

Thank you for the question.

You're right, it's outside of the area of my expertise, certainly, but I do know that the future generations commissioner has invested significant time and research into this, and the national food strategy that they propose would look closely at what we can and can't grow. Obviously, we can't, as a nation, grow everything that we need to consume—we're not there yet—but there is certainly more that we do already grow that could be used more effectively to supply our own schools, our own hospitals. So, it's not all or nothing; there is much more that we can do, and we should be doing, really, in the spirit of the future generations, to protect all of our futures.

Okay. Accepting that, we would need to see evidence, I suppose. If we're going to go down this route of trying to call for local produce, we would need to talk with agricultural bodies and other food-producing bodies. But, on that point, there is food being produced in Wales, isn't there—seafood, which is exported to France and Italy, and even to Korea. Welks: most of—. Ninety per cent of our welks end up in Korea, when we have this good, healthy, full-of-protein local produce. Pheasants—pheasants are shot here; we have many shoots. That produce that could be in our schools and in our hospitals, but it's not. So, just your opinion, very quickly, about whether you think we should promote and encourage more of the natural seafood produce that we have, and the shoots that we have. Should we use that produce in our schools, and encourage our children to understand where this food comes from, and the value of it?

A very short answer: yes, completely.

Absolutely. We have started; Welsh Veg in Schools is a programme that's been supported. We can't grow everything—that's what Rocio said earlier—but we need to draw on children knowing where food comes from. As part of my role, I've been into a school, and watched what they were eating. And it was nice, actually, to see that they were eating fruit and preferred that over maybe a pudding. But it's watermelon—again, where does it come from, what is the environmental impact? And we also know from young people, especially—the college does a lot of work with young people—that young people are worried about our planet. So, we have to really take this into account and make it sustainable. I'm not proposing that we grow watermelons, but we can grow a lot of vegetables here, like you said. We've got resources, and we must use them.

Could I ask Dana, seeing as you've just responded to that, in terms of paediatric health, child health, what's the evidence that you've seen of what happens to a child when they take in too much fat, sugar and salt, not only that they become obese—we see that as a result of the food that they're taking in and the lack of physical activity that they do—but what else happens to the child in terms of their general health, in terms of their mental health, or their relationship with their friends? Is there something beyond obesity happening to the child?

Yes, sure, there is. So, we do know that, children referred to weight management services, about half of them have already got metabolic underlying issues. They've got insulin resistance, which means that they are far more likely to develop a type of diabetes in the future. So, there are children as young as five who need medication. We have a number of children with non-alcoholic fatty liver disease, and that's not a small number. I can't give you any numbers, but I'm sure I could produce some later on. The number is going up. Unfortunately, we see evidence of malnutrition, really. Because our children are not enough outside, there's not enough vitamin D. So, so many children are deficient in vitamin D. And also—I never thought I would see this in my lifetime as a paediatrician in a developed country—I've seen children with vitamin C deficiency, scurvy. This is something out of books from pirate stories, long, long ago. So, we have seen children in Wales with vitamin D deficiency. It's tragic, it's—

Vitamin D or C, did you say?

Vitamin C.

C.

Yes. Vitamin C deficiency is rare, but I've seen it—there have been several cases. But vitamin D deficiency is more frequent. And it's heartbreaking to see because, already, our children are not well. We're already robbing them of a healthy adult life before they even start school, because they are just not well. And, like you said, it then has an impact on their emotional and mental well-being, because they are likely to be bullied, then they withdraw and then just go back to their bedrooms. And then, of course, there is all the technology, and they will not engage in outdoor behaviours and being with their friends and do what they should be doing.

Can you just tell us what are vitamin C foods?

It's lemons, oranges, apples. Vitamin C is in lots of—. But, yes, mostly oranges and things like that.

Blueberries. Strawberries. Lovely.

Yes. All the fruit, really.

Yes. Mabon, any further—?

Okay. If I could just follow up on that, Chair, with your permission, you mentioned there, Dana, children not being able to get vitamin D, and that's shocking—it comes from the sun, and from children being outdoors, they should be getting vitamin D. We hear that children are football mad and enjoy these things, but they're not engaging in physical activity. What's your opinion, from your experience—and Rocio too, in this regard—of technology, which you've touched on, and children staying indoors and playing computer games, children being on phones, in bed, talking to each other online, which is good in terms of mental health—?

I know that Rocio wants to come in on this, so maybe I'll let her speak first and then maybe come in later.

Diolch.

I can see Mabon has frozen, but continue in any case.

Okay. Yes, there is a huge society-wide challenge that we're all facing currently in relation to screen time. We know there's a big debate about whether or not mobile phones should be allowed in schools and so on—I won't go into that—but, overall, there's huge evidence that screen time is increasing for children and young people, and that it's having a really detrimental impact on their physical health, their mental health and their education and their social skills. So, we know those things from the evidence.

I've seen concerning evidence recently about the impact of parental screen time on young children, and the potential for that to impact on children's development and their readiness for school. So, there's a suggestion that that might be one of the factors behind more reception-age children not having basic speech, not being toilet trained, not having sufficient core strength to sit on a carpet, as is normally required when children are in reception, because those children have just spent too many hours on screen time themselves. So, there is huge evidence, and this is, yes, a huge society-wide challenge. It's not just about children and young people's use of screens; it's about everyone else, the adults around them, and the impact on children. We are all role-modelling to children what is quite damaging, potentially harmful, behaviour. So, I think we need to take a look at ourselves a lot of the time in trying to come up with some of the solutions. But, certainly, I would love to see not just a discussion about how screen time can be restricted, but what positive alternatives can be offered to children and young people, so that they can actually go out and play and exercise. So, we need much more investment in those facilities, to give children those opportunities—not just telling them what not to do, but giving them actual opportunities of what to do.

Sure. Do you have any further questions on—? Sorry, Dana, do you want to come in?

I wanted to come in on this. There's been published research from 2021—. We've got a Welsh institute for physical activity in Swansea, and they worked, on a broader scale, with 60 other countries, and we've been the worst. We got an 'F' in physical activity for our children. So—

Across which countries was that survey taken?

It was 60 countries across Europe.

And we were at the bottom?

We were an 'F'. So, that was, like, A to F, and we're just the worst, in Wales.

Joint lowest out of 57 countries.

Yes. Joint lowest.

Okay. Just for context, then, were there lots of countries in that 'F', or were we just one of few?

I've got three. Joint lowest with three other countries.

So, out of 60 countries, we were the lowest in terms of that data?

Yes.

With three others—two others. Right.

So, we know that children over five and young people should move for an hour a day every day, but research has shown that probably 20 per cent of boys maybe do that and 14 per cent of girls. That's shocking. It is absolutely shocking. So, again, we need to make it the norm. We need to inspire our children. We need to have the provision that children can be outdoors, they can be active. And, again, it's so multifactorial; there's not a single answer for this, but it is healthy environments, it is green space, it is safe spaces for children. In the cost-of-living crisis, when parents have to decide whether they pay food bills or they pay energy bills, they're not going to splash out on trainers for their kids to take part in football. So, we really need to tackle this because that is a huge problem.

How?

Very good question. Again, I think—. Have you got something?

Yes. So, we've made several recommendations to the Welsh Government about increasing opportunities for children to be active. One of those is that we recommended that they invest more in delivering the daily active programme, which is run by Sport Wales and works with schools to support teachers to help children to be active during the school day. I think that investment or that programme was kind of on a pause, as far as we could make out, so it doesn't really seem to be running fully, as it was intended to.

We've also called for local authorities to do as much as they can to protect budgets for leisure and sport facilities in this difficult cost-of-living crisis. But, really, we would like local authorities to fall under the same duties as, currently, Welsh Government Ministers have, to formally consider the impact on children's rights of all of their decision making. So, we have called for the current duty, through the Rights of Children and Young Persons (Wales) Measure 2011, to be extended to apply to local authorities. And we feel that would make a big difference to the decisions that are being made in local authorities around Wales—you know, we all hear about swimming pools being closed, parks not being available because the councils can't afford for wardens to lock them up and open them and that kind of thing. So, this is a big issue that, I think, needs proper investment and proper scrutiny.

Sure. Thank you. I'll bring Mabon back in a bit later. John Griffiths, do you want to come in on your questions?

Thank you, Chair. Good morning, all.

I have some questions initially on child measurement programmes and the support available to children. Firstly, how effective is the national child measurement programme in measuring being overweight and obesity in children, and would you point the committee to any improvements that are needed to that programme?

Do you want me to go? I think we have some data that the child measurement programme gives us when we measure children when they're in reception, aged four or five, for their height and for their weight. And that is just one point in time, really, isn't it? So, there should be a lot more data available for children when they're seen in healthcare, when they present for surgeries. We know that, in England, children are weighed and measured again when they're in year 6, so when they're 10, 11 years old. It would probably be useful to have that data and extend it to Wales. There are some concerns that it might negatively affect some children who are very weight conscious, and we, in health, really want to focus on—we want to be weight neutral—health and well-being. But—and you've heard this before—there's evidence that children are shorter and they don't grow as tall as in other countries due to poor nutrition, due to poor physical activity. So, I think it might be useful to collect that data.

What we then do with that data and how we can support those children are entirely different questions, because we do have the obesity figures, and you all know that obesity is still up in children, that it's strongly linked with deprivation, where the obesity figures are almost double compared to the least deprived areas. So, again, we should make every contact count, but these children who are obese already at a young age, they do need support, and that support is very sketchy. We have some obesity services in Wales, in four out of the seven health boards, but the two health boards—. So, Cwm Taf, which has got the biggest obesity rates, hasn't got any sustained level 2 or level 3 obesity services. Hywel Dda, which has got the biggest rate of overweight children, with about 28 per cent of children, hasn't got any services at all. So, that's not right. We need to make sure that we can support these children early on, because if we don't do this now, then, in 20, 30 years' time, we'll see the consequences, and now there's a time to intervene. So, we would recommend a focus on behaviour-changing interventions for the child, for the whole family, and there's evidence that that works.

Can I just ask, if you don't mind me jumping in, John, on those two health boards that you referred to that don't have those services, why is that? Is that funding? Is it to do with not having the specialists available?

It's mainly funding, and a little bit of the specialties as well. If you don't really have any money, you won't attract any people. The problem with a lot of projects is it's always short-term funding. So, I know that Cwm Taf have done a business plan but haven't been able to get any funding. But, for the services that are available, for instance in Cardiff—I've been in touch with one of my colleagues—the numbers are stark. So, three years ago, they had 150 children a year referred; the following year it was 300 and last year it was 450. So, the numbers go up, and up, and up. We do need to look at that. We need to have an equitable service across Wales for these children.

And how does that happen?

Unfortunately, it does need an investment. So, there have to be a few more seats there, a few more people and investments, but we also need to rethink. It can't just be more money and more people; we have to rethink what we do, and we have to draw on pilots, projects and research. There has been some work done that did digital transformation. So, there's been a pilot programme where children who've been referred to the obesity service and their parents were wearing some wearable technology, or a Fitbit, and that can be monitored from afar, so they can be incentivised via an e-mail; it doesn't need clinic appointments. So, we need to look at how we actually use the services in a better way.

Sure. Lovely. I'm just conscious that John's got quite a few questions to get through as well, so keep that in mind. John.

Diolch, Cadeirydd. In terms of the link between mental health and obesity, is that sufficiently taken into account in relation to children and young people, or should Government policies and weight management services take that into account to a greater extent?

I'm not familiar with research that shows a definite link, but my instinct would say that I would agree that there probably is a link. I think some of this would link back to the stigmatising effect of the language that we use around obesity and weight, which would impact on children from a very young age. If they become overweight or obese, then there is a very negative stigma attached to that that will potentially lead to bullying, and, of course, impact on their mental health. I know from the engagement exercise carried out for this inquiry that many of the adults that you spoke to for that spoke about the real impact on their own mental health due to stigma, you know, barriers in getting out and taking part in normal daily activities due to the stigma that they felt related to their weight. So, I think that there is definitely a huge link. I think it might be useful to explore the link further, particularly in relation to children and young people. I'm not aware of any research that has done that. However, again, I would say that there is a bigger underlying factor beneath both obesity and mental health prevalence, which, unfortunately, comes back to poverty and material deprivation. We can invest so much time looking at, 'Is there a link between obesity and mental health?', and we'll probably end up with 'yes', and the common denominator is poverty and not being able to afford good food and activities—football trainers, as Dana said.

Thank you. I just want to check, John, do you want to come back in, and then I'll bring Dana back in after that?

Yes, sure. I think it would be useful for us as a committee just to know anything specifically that you think should be done in terms of those mental health and obesity issues and the way that services are delivered.

I can speak to that. I think there's a definite link between mental health and obesity, but, again, we can't just see things in isolation because everything is interconnected. So, I think, as paediatricians, we have seen an increase in mental health problems over the last few years, probably triggered by COVID, and we had to upskill our workforce. So, the royal college has extended its training on mental health, because it's so, so important. We want to feed this through the whole of paediatric contacts, not just to obesity. So, when children and young people come to my clinic, we will explore mental health, mood, school, attendance, stuff like that. So, we really want to have a holistic approach, and that needs to feed through. We are training up the workforce specifically for obesity, enquires about stigma, about language, using a trauma-informed approach, and that's really important.

But, coming back to the service provision, I've spoken to that before as well, but one point I wanted to mention as well: we also need to look into the future, and we can see what's happening in the adult world at the moment with medication. That seems to be a little bit of a disaster. Medications aren't licenced for children yet, but it's on the horizon, and we can expect that, in a few years, that may happen. So, the work needs to start now. What are we going to do? Do we want to medicate our children? Is the side-effect profile acceptable? I wouldn't say so. But that's something that we need to draw on from the adults and we need to be prepared.

Sure. Thank you. John, have you got any further questions? I'm just conscious we're running a little—. Time is a bit short, so perhaps just slightly shorter questions. Sorry to have to ask that. John.

No, that's fine.

Okay, if we move on to the focus of 'Healthy Weight: Healthy Wales', the Cabinet Secretary for Health and Social Care recently told the Children, Young People and Education Committee that there could be more of a focus on childhood obesity and overweight in the new 'Healthy Weight: Healthy Wales' delivery plan. I just wonder what our witnesses make of that, and are there any particular ways in which they think the plan could be strengthened.

Julie.

So, obviously, I want to come in to pick up our earlier conversations, which would be about increasing the support and commitment to breastfeeding, because that, evidently, would give all children and all families the best start in life. So, I would absolutely recognise what's being advocated there, and that's what we would, as the Royal College of Midwives, be advocating as a key recommendation.

Dana.

Just making the healthy choice an easy choice, implement healthy behaviours and address the regional variations in services, but again—

How do you do that?

Well, it's got be investment and looking at technology. And then it comes down to poverty as well; we need to lift children out of poverty. That is the key to a lot of health inequalities and health issues that we're seeing.

I think I’ve welcomed the focus that the plan has on prevention and building a healthier environment. I still have concerns about the name of the programme and the focus on weight; I think it’s potentially stigmatising. I would like us to, rather, focus on health and well-being.

And I’ve heard that there are potential discussions under way about whether, potentially, to look at calorie labelling. I would urge caution on that, and draw attention to the fact that the evidence is currently inconclusive about whether calorie labelling actually has a positive impact on weight monitoring and obesity. There are known disadvantages and impacts on young people with eating disorders and so on. So, I would urge caution, and to, certainly, only proceed on the basis of the evidence.

John.

Do you think that progress can be fairly easily measured in terms of ‘Healthy Weight: Healthy Wales’?

I think there’s a tendency to use the weight measures as the indicators of success, but, as I’ve already said, I think that is the wrong focus. So, I would rather have measures that look at other outcomes, other outcome indicators. I think addressing the disparities is a really important aspect that I would like there to be greater focus on.

Yes. Perhaps I could just finally ask, Chair, as we’ve heard, there are quite a number of factors involved in obesity—social, economic, commercial, environmental—taking everything into account, is there anything in particular that you’d like to flag up to the committee, in terms of key actions that need to be prioritised in the short term and long term, to address childhood obesity levels in Wales?

I’d just like to draw attention to the new regulations for food in schools that are due to come in. I’m not clear how those new regulations will be monitored and how food in schools will actually be tested, and whether children and young people will be any part of that. So, I would really love to see them directly being able to be part of that monitoring framework.

Okay, that's good. Anybody else on the panel want to address John's last question?

I think I’ve actually said my bit. We need to make sure that we lift children out of poverty, that the regional services work in partnership, and have a whole-system approach, looking at children holistically. But we also need to—. I often find that policies and decisions are made without children in mind because children are generally thought to be healthy. We need to make all our decisions with children, with the next generation in mind, and actually ask ourselves, ‘Is this going to be to the benefit of children, or is it going to be detrimental?’ because that’s so, so important.

We need to invest in the early years. You’ve heard that before, and I think this is our only way out of this crisis. And that’s an investment that will be well spent, because we need to prevent this ill health, and it is preventable. So, if we invest in early years, like we've said before, with the longer breastfeeding, with support for children and families living in poverty, with the school food, with the change in curriculum, with bringing children outdoors more—you heard evidence on that before—that needs to all be joined up, and, hopefully, that way, we can actually make an impact.

Anything new to add, Julie? Don’t worry if not.

Well, I think, just picking up, as well, as we're progressing through that investment into the early years, that investment also into the pre-conceptual, so, really focusing on the women’s health plan priorities—again, another great ambitious plan, with so many recommendations. But, again, if we continued to have that focus into pre-conception, then we’re going to reduce obesity in pregnancy, which is then going to improve the health and well-being of our women and our families, and, then, also have that continued positive impact on the continuation of breastfeeding, so, it is a complete lifecycle.

Sure. Thank you, John. I know you may have to disappear, so it's no problem if you disappear off our screens. Mabon ap Gwynfor.

Thank you, Chair. You've mentioned the role of schools. The Government, of course, has said that they've committed to reviewing the regulations on school food nutrition and the nutritional standards and guidelines. So, what do you think that Welsh Government should consider as part of this review, and how easily available is information on current compliance with nutritional standards in our schools?

Maybe if I start on this, because I actually was—. So, the Royal College of Paediatrics and Child Health has been part of the task and finish group to look into the standards for school food. Personally, if I can be honest, I have to say that I welcome that this is happening but how it has been gone about wasn't quite right, because I think it needed to be led by public health and health, rather than by caterers. So, I want to say that that maybe—. So, we voiced our concerns that we feel that we need to be more ambitious. We can't change our regulations every five years, but we need to be ambitious, we need to change food culture. There is no need for every child to have a pudding every day; we need to address portion sizes; there is no need for them to fill up on bread; they should have access to fruit; they should have access to water; and we should limit processed food. So, these regulations are under way and they will be tested, and, the last time that I was involved, we had some proposed standards and some aspirational standards. So, in my view, we should go for the aspirational standards, but then, of course, nothing is black and white and easy to take forward, because we do hear from the caterers that you could put oily fish in front of the children and they wouldn't eat it. So, we need to gradually change food culture and expose them to new foods, and that will happen over time. It can happen, and children can adapt. So, we welcome that.

You touched on the point that all of this work is worth nothing if it's not implemented in the proper way. So, with the guidelines, then, their implementation will need to be monitored and, so far, that's not really been done. And with the free school meals provision, which we welcome, we need to use that opportunity to just give our children the best food, because for many children it's the only food they're going to get in the day. So, yes, it does need to be monitored and we need to be aspirational there, but I know that money is tight. So, yes, it's tricky.

If I can go back one step, a few years ago, you'll remember the big row around Jamie Oliver's campaign on turkey twizzlers, and the media drew attention to it and it brought it to the top of the agenda that food had to be improved in schools. How far ahead are we now? Have we gone forward with this, or is there more to be done?

The short answer is that there's more to be done.

And what's the longer answer?

I want to give my colleagues here—. I've talked a lot. I'll give someone else an opportunity.

Yes, I agree that there's more to be done. The universal free school meals provision in primary schools is a huge opportunity and a huge investment that needs to be maximised. My office did a survey on school dinners with children last year, and we had about 1,200 children take part. The main message they told us was that the school dinners weren't big enough, the portion size wasn't sufficient, particularly, for their age. There were children telling us that they were getting the same portion size whether they were in year 1 or year 5. And a quarter said that they couldn't have more vegetables if they asked, or around the same said that they couldn't have more fruit. So, I think the point about filling up on bread, I would agree with.

But, yes, in terms of the food regulations and the opportunities those bring, I would agree completely that we do need to be more aspirational. We do need to make children's and young people's voices and their health the driving priority in this conversation. We know that the consultation on the regulations will come out, hopefully in the spring, and we’ve heard that there’ll be targeted work with children and young people as part of that consultation. So, we really hope that that consultation is meaningful and that what children say is actually listened to, and it’s not just a tick-box exercise. But once those regulations are in place, coming back to the monitoring and the compliance aspects, they will be fundamental. These things can really connect with all of the conversations we had at the beginning of this session about helping children connect with food, understand what it is, where it comes from, grow their interests in food, and that will all lead to healthier choices and healthier behaviours longer term.

So, to elaborate on Dana's point around the culture of food that needs to change, I'm just thinking, do you have any ideas about changing the culture, because I'm aware that the UK Government helped to change food habits in the UK back in the 1970s? Back then, if I can take you back to that post-war period, people in Wales and the UK were eating kippers for breakfast; cockles were a very common part of our diet. A variety of seafood was part of our diet, and now seafood has been restricted to only five types of fish. But we have a large amount of food that could be included and that is healthy. But, as you were saying, Dana, if you gave kippers or herring to a child today, they would step back and say, 'No, I don't want to eat it.' So, how can we, in terms of the psychology of it, encourage children to eat different food—not only children, but their families as well, to buy into that? What are those nudge steps that the Government and we have to take in order to change that food culture? I don't know, perhaps you're not experts in psychology and so forth, but do you have ideas around that?

I can start by saying that population behaviour change is a huge challenge. I think awareness campaigns play a significant part, but we have to be better than the huge advertisers at this. The new regulations brought in by Welsh Government around restricting the advertising of unhealthy food, I welcome that. I think this is part of the solution, making the unhealthy choices less visible, less attractive, less strategically placed. I asked children for their views on this in September. Again, there was strong support for the idea that the positioning of food in supermarkets did make a big difference to them as to whether they bought them or not. Sixty per cent said that this does make a difference to them, and 72 per cent told us that buy-one-get-one-free deals on unhealthy food also make them more likely to buy those products.

So, I think rules and regulations have a part to play, but then hearts and minds in terms of proactively encouraging healthy choices is a different matter, where public health awareness campaigns can play a significant role. But actually bringing those into children’s lives through schools, through community food projects, is where it can actually really start to make a difference.

Absolutely, and just coming in there, I think, from my point of view, it's recurrent exposure, that's what children actually—. They are naturally curious. If you just change the menu and give them lava bread and mackerel, they're going to run, but if we just have—. If we get them engaged, if we educate them about healthy food, then they'll ask us, 'Well, how do I get this?', 'Well, by eating fish', 'What fish?' And by education and recurrent exposure, and having also—we discussed this in a task and finish group—trial menus, that we have little bits that they can try one week, and then that way, hopefully, over time, increase the uptake, because that's what psychology and behaviour research has shown, that it needs recurrent exposure. On the first one, you probably won't eat that, but also, peer pressure on children; there are a lot of children who won't eat anything particularly healthy at home, but they will eat it in a childcare setting because the other children do that. So, we need to draw on that.

Okay. Any other further questions, Mabon?

They've answered everything that I wanted to ask, so thank you, Chair.

There we are. Thank you. And just finally, are there any other countries that we can look to when it comes to good examples in terms of reducing childhood obesity?

The Royal College of Midwives are certainly looking across to our Scandinavian colleagues.

Yes, it always comes up, Scandinavia.

Yes, so particularly the Royal College of Midwives Scotland are doing some comparative work with some outcomes for Scotland maternity services versus some comparatives with the Scandinavian services. But that's just an early—. And I did notice from the Public Health Wales submission that they had also drawn on some good stats from Norway.

Okay.

Again, I would reference the Public Health Wales report from 2018. That was a full comprehensive review of the international evidence. They've looked at everything and drawn out some really important themes. I think some of the themes that they'd drawn out as to what made for a successful approach included multilevel action across different sectors, including schools, communities, early years settings, industry and local leadership. I think strong leadership was a key factor they highlighted, and community participation, mobilising existing structures and assets within the community, so very much a community assets-based approach.

And then, one that just struck a chord with me was from Canada, where, in that example, they said that they had emphasised that their summary was that health is much more than weight, and cautioned that an overemphasis on weight is stigmatising and doesn't address many of the underlying factors contributing to unhealthy weight. So, that was just a line that particularly struck a chord with me.

Okay, thank you. Thank you very much. Is there anything final that you wanted to add that was important for our work in terms of any recommendations you think that we should be putting to Government, or do you think you've covered the areas that you wanted to address?

Thank you.

Thank you very much. In that case, thank you so much for your time and advance papers, and also we'll send you a transcript of proceedings for you to have a look over as well, but if there's anything you want to add further following today's session, then of course we'd welcome that. But diolch yn fawr iawn, thank you very much.

I move to item 4. We have correspondence from the Petitions Committee regarding health-related petitions, and also we have got various correspondence from the Welsh Government in regard to regulations and other matters. Are Members content to note those papers that are in the public pack? Thank you, they are. That's agreed. In that case, that draws our public session to an end today. Diolch yn fawr iawn.